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  • 1. HIV Dermatology: Case-based Presentation Toby A. Maurer, MD Associate Professor University of California San Francisco The International AIDS Society–USA
  • 2.
    • 38 y.o. male has been on and off ARVs for 2 yrs, secondary to substance abuse
    • New lesions on legs
    • CD4 80, VL 80,000
    • Restart Antiretrovirals (ARVs)
    • Special clinical features:
      • edema lower legs/ groin region
      • woody feeling to upper legs
  • 3.
    • If lymphedema, ARVs may not be enough
    • For those who need chemotherapy, liposomal doxorubicin is first line chemotherapy in this country
  • 4.
    • Pt does not have swelling-so you convince him to get back on ARVs
    • He is anxious-how long will it take to get rid of these?
    • Ave: 9 months
    • Doesn’t want to live with lesion on his face
      • intralesional vinblastine
      • radiation therapy
  • 5.
    • He tolerates his ARVs and is adherent to regimen
    • Notes abdominal pain and bloody stools
    • Old cutaneous lesions popping out/enlarging
    • Still no swelling in ankles
  • 6.
    • You suspect KS immune reconstitution (IRIS)-just skin and tolerable
      • Continue ARVs; will stabilize in 16 weeks
    • Systemic involvement-GI, pulmonary-start liposomal doxorubicin
    • Do we have labs that indicate IRIS?
    • Do we have a way to work up pts with KS to predict systemic involvement?
  • 7. Did you biopsy?
    • Biopsy of KS is always useful
    • Early detection is the name of the game- if you don’t start ARVs within a year of KS presentation, mortality is the same as in the pre-ARV era
    • Several skin conditions mimic KS. A real diagnosis is useful
    • Pt may fail ARVs or need adjunctive therapy with chemotherapy or radiation therapy-need tissue
  • 8.
    • Abolulafia DM et al. Regression of AIDS KS after HAART. Mayo Clin Proc . 1998 May.
    • Udharain A et al. Pegyalted liposomal doxorubicin in treatment of AIDS. KS Int J Nonomed . 2008.
    • Nguyen HQ et al. Persistent KS in HAART era. AIDS . 2008 May.
    • El Amari EB et al. Predicting evolution of KS in HAART era. AIDS . 2008 May.
  • 9. Kaposi’s Sarcoma
    • Majority of KS seen with CD4 <200 and VLs that are mounting
    • Your pt has CD4 of 450, VL 8000-do you start ARVs?
    • Yes-we have found that within months CD4 declines and VL starts mounting
  • 10. Kaposi’s Sarcoma-new group
    • 17 patients with CD4 over 300 and VL<75 for more than 2 years with new or persistent KS
    • All on ARVs and doing well
    • Ave age 51 (range: 41-74 yrs)
    • Ave duration of HIV: 18 years
    • Ave length of time on ARVs: 7years (1- 19 yrs)
  • 11. What is going on?
    • HHV8 virus-unusual type or unusual behavior
    • Functionally abnormal T cell response to HHV8
    • Immunosenescence-the aging immune system of HIV-infected, treated individuals
  • 12.
    • How do you manage these individuals?
    • To date, they have not had systemic involvement or eruptive KS-reassure
    • Local therapy to include radiotherapy and intralesional therapy
    • Monitor closely re: HIV status (no change to date) and other co-morbidities of the aging immune system
    • Let us know- [email_address] or 415-206-8680
  • 13.
    • Maurer T et al. NEJM . May 2007, Sept 2007.
    • Dittmer DP et al. NEJM . Sept 2007.
  • 14. The skin as a window to the immune system
    • Pt known to you to have psoriasis. Walks into ER with thick, oozing plaques
    • Could this really be psoriasis?
    • Is this infected psoriasis?
    • Suspect change in pt’s CD4 count, VL
    • Look for resistance
  • 15.
    • First line therapy: ARVs
    • ARVs turn off psoriaisis before CD4 count increases or VL declines
    • ? Anti-inflammatory mechanism??
  • 16.
    • Pt also has pulmonary TB-can’t start ARVs yet until his TB is treated
    • What about his psoriasis? Start acitretin 25 mg qd-this is a retinoid designed specifically for psoriasis
    • TB under control-start protease inhibitor regimen-acitretin still on board-watch for retinoid toxicity-monitor cholesterol, TG, painful red skin-can probably discontinue acitretin
    • Tx with topical steroids
  • 17. Other Markers of Poor Immune Status
    • Prurigo nodularis
    • Pruritic papular eruption of HIV
    • Molluscum
  • 18.
    • Prurigo nodularis-pts consumed by itch
    • CD4 under 100 with VL
    • You start new ARV regimen in this patient-can’t get the CD4 count above 60 but VL is low
    • Topicals include clobetasol oint (class 1 steroid) and doxepin 50 mg qhs
    • Thinking about adding thalidomide
    • Is pt a candidate for raltegravir?
  • 19. Pruritic Papular Eruption
    • 86/102 biopsies showed evidence for arthropod assault in Ugandan study (Resneck J. JAMA . 2004)
    • The more severe the eruption, the lower the CD4 count (p< 0.001)
    • Persons on ARVs improve with 16 wks of therapy (Castelnuovo B. AIDS . 2008 Jan)
    • Hypersensitivity to bug bites may be secondary to T cell dysregulation
    • Resneck J, et al. JAMA . DEC 1, 2004
  • 20. Molluscum
    • 1st line therapy is ARVs
    • Liquid nitrogen only temporary
    • Curretage of large molluscum
    • Cryptococcus can mimic molluscum but lesions develop quickly over days
  • 21. New Directions
    • Can we use these skin diseases as markers for virologic response?
    • If these recur on treatment, does it indicate drug resistance or non-adherence?
    • Particular importance in resource poor settings/children with HIV/as a clue to look for resistance-obtain CD4 count, VL
  • 22.
    • CD4 250, VL < 50, admitted for IV vancomycin for cellulitis
    • Blister on back-is this a new area of methicillin resistant staphylococcus?
    • Call dermatology-consider toxic epidermal necrolysis
  • 23. Toxic epidermal necrolysis
    • Complete separation of epidermis
    • Watch for triangular blisters
    • Higher incidence in HIV
    • Higher mortalitiy in HIV
    • TMP-SMX/vancomycin
    • Intravenous immunoglobulin (IVIG)???
  • 24. Drug Reactions
    • NNRTIs-redness-treat through
    • NNRTIs- erythema mutiforme-discontinue drug and don’t rechallenge; change class of drug
    • Abacavir-5-8% develop hypersensitivity rxns-HLA B*5701+ higher risk
  • 25.
    • 2 cases of erythema multiforme to raltegravir
    • Fixed drug reactions to darunavir
    • Do not give prednisone unless hypersensitivity marked by transaminase or creatinine elevation
    • Syphilis-widespread erythematous maculopapular eruption-check RPR-usually does not itch
  • 26.
    • Pt with CD4 140, VL 100,000-starts ARVs
    • New pruritic bumps on face, scalp, chest, back (within 3 weeks of starting ARVs)
    • He felt it was a drug eruption and so discontinued his ARVs
  • 27. Eosinophilic folliculitis
    • CD4 counts under 200
    • Develops within 3-6 months of initiating ARVs-immune reconstitution
    • Itraconazole 200-400 mg /day
    • Permethrin from waist up
    • UVB
    • Wait for immune reconstitution to settle (3-6 months after starting ARVs)
  • 28.
    • Differential diagnosis
    • Acne-seeing lots of it as a result of normalized immune systems and drug induced acne (testosterone, INH, lithium)
    • Doesn’t itch and not on scalp
    • Staphyloccocal folliculitis-increased incidence in HIV infection-easily denuded pustules (not on scalp)
  • 29.
    • Pt admitted with painful leg with erythema-admitting diagnosis = cellulitis
    • Developed pustules
    • Discharged on antibiotics-now pustules all over body
  • 30. Herpes zoster
    • CD4 between 200-400, VL 70-100,000
    • Disseminated zoster-seeing it more often in pts on and off ARVs
    • Recurrent zoster with high CD4 counts-would that lead you to place pts on ARVs?
    • Glesby MJ et al. JAIDS . 2004 Dec.
    • Abbas V et al. Am J Med Sci . 2001.
  • 31. Herpes simplex
    • Have never seen disseminated herpes simplex in HIV
    • Pt presents with large hypertrophic and painful lesion perianally
    • Must rule out squamous cell carcinoma
  • 32.
    • Diagnosis-herpes simplex
    • Send for acyclovir resistance testing
    • Pt will need foscarnet/cidofovir +/- topical cidofovir
    • Levin et al. Clin Inf Dis . 2004.
  • 33. Squamous Cell Carcinoma
    • Several cohort studies have now documented that there is a higher incidence of SCC and BCC in HIV
    • Risk factors: being white, increasing age, longer duration of HIV infection
    • Low CD4 counts not a significant variable for tumor initiation
    • Sun and smoking
  • 34. Melanoma
    • Melanoma in HIV may be more aggressive when compared by tumor thickness
    • Sentinel node biopsy recommended at shallower thickness-usually do sentinel node if melanoma is 1mm or more in thickness
    • Recurrent melanoma more frequent
    • Max out the immune system-start ARVs